ACP HospitalistWeekly

In the News for the Week of April 11, 2012

Highlights

Keynote speaker Wachter addresses record number of attendees at HM 2012

SAN DIEGO—Hospital Medicine 2012, the annual meeting of the Society of Hospital Medicine, brought more than 2,500
hospitalists to San Diego this week for the largest ever gathering of the specialty. More...

Infection, other factors may increase risk for VTE hospitalization

Infection, treatment with erythropoiesis-stimulating agents, and blood transfusion may increase risk for hospitalization due
to venous thromboembolism (VTE), according to a new study. More...

VTE prophylaxis

UFH, LMWH similar in cost, efficacy for VTE prophylaxis

Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) have similar costs and effectiveness for venous thromboembolism
(VTE) prophylaxis, but LMWH is associated with fewer complications, a new study found. More...

Adverse drug events

Fluoroquinolones associated with retinal detachment

Current users of oral fluoroquinolones are nearly five times more likely to have a retinal detachment than nonusers, although
the absolute risk was small, a study found. More...

From the College

Attend a chapter meeting

Clinicians can enhance their clinical skills and knowledge and network with colleagues at local ACP chapter meetings. More...

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Vote for your favorite entry

Editor's note: There will be no ACP HospitalistWeekly on April 18, due to preparations for the Internal Medicine 2012 meeting in New Orleans on April 19-21. Our April 25 issue
will feature highlights from the meeting.

Highlights

Keynote speaker Wachter addresses record number of attendees at HM 2012

SAN DIEGO—Hospital Medicine 2012, the annual meeting of the Society of Hospital Medicine, brought more than 2,500
hospitalists to San Diego last week for the largest ever gathering of the specialty.

After three days of scientific sessions, Robert Wachter, MD, FACP, closed out the meeting with an address on "The Great Physician
2012" in which he warned attendees about significant changes in store for physicians, but also reassured them that hospitalists
are well-positioned to lead the future of medicine.

He noted many positives of contemporary hospitalist practice, including improved quality and safety and potential for cost-cutting,
but he also discussed potentially negative aspects, especially related to an increasing focus on technology. Hospitalists
should be "constantly asking ourselves what we have lost in terms of our relationship with patients" because of computers,
Dr. Wachter said. He also expressed concern that physicians' body of skills and knowledge could shrink due to their reliance
on technology and instant access to information, asking "Is Google making us stupider?"

Dr. Wachter encouraged hospitalists not to let ongoing efforts toward better teamwork distract from the need for strong leadership
within the hospital. "Teamwork is absolutely vital and yet I've been to a lot of institutions that seem to be really good
at teamwork, but what they're missing is leadership. I think we've got to be a little careful about going too far in the Kumbaya
direction," he said.

Dr. Wachter will become chair of the American Board of Internal Medicine (ABIM) later this year, and he discussed the challenges
of assessing the competence of current and future internists. Other forums for physician assessment (such as HealthGrades)
may make the public less concerned about board certification, while the increasing complexity of practice—for example,
the need to judge a doctor's team behavior, systems thinking, and professionalism as well as clinical knowledge—makes
assessment more difficult.

He predicted that a component of the ABIM exam will allow use of the internet within the next five to ten years, although
he also expects part of the exam to continue to rely on memorized knowledge. "It's vital that we don't ditch all of the old
competencies," he said. He closed his speech by reassuring hospitalists that these changes will not be too much for them to
handle. "If any field is going to sort out how to be this new great physician while holding onto the parts of the old great
physician that have enduring value, it will be us," he said.

Infection, other factors may increase risk for VTE hospitalization

Infection, treatment with erythropoiesis-stimulating agents, and blood transfusion may increase risk for hospitalization due
to venous thromboembolism (VTE), according to a new study.

Researchers used data from the Health and Retirement Study, a nationally representative, ongoing, longitudinal study of Americans
at least 51 years of age, to perform a case-crossover study examining risk factors for VTE hospitalization. Data from the
study were linked with Medicare files for hospital and nursing home stays and emergency department, outpatient and home health
visits from 1991 to 2007. The authors compared exposures to potential risk factors in the 90 days before hospital admission
in patients admitted with a principal diagnosis of deep venous thrombosis or pulmonary embolism to the same patients' exposures
during the four previous 90-day periods. A 90-day washout period was observed between the risk and comparison periods. The
main outcome was hospitalization for VTE. The study results were published early online April 3 by Circulation.

A total of 16,781 patients with 399 index VTE hospitalizations were included. The most common predictor of hospitalization
for VTE was infection (52.4% of risk periods), with adjusted incidence rate ratios (IRRs) of 2.90 (95% CI, 2.13 to 3.94) for
all infection, 2.63 (95% CI, 1.90 to 3.63) for infection without a previous stay in a hospital or skilled nursing facility
and 6.92 (95% CI, 4.46 to 10.72) for infection with a previous stay in a hospital or skilled nursing facility. An association
was also seen between VTE hospitalization and treatment with erythropoiesis-stimulating agents (IRR, 9.33; 95% CI, 1.19 to
73.42) and blood transfusion (IRR, 2.57; 95% CI, 1.17 to 5.64). Major surgeries, fractures, immobility and chemotherapy also
appeared to contribute to VTE hospitalization risk.

The authors acknowledged that their study database was relatively small and that information on oral medications was not available,
among other limitations. However, they concluded that infection, erythropoiesis-stimulating agents and blood transfusion are
associated with increased risk for VTE hospitalization and that risk prediction algorithms should be updated to include these
factors.

An accompanying editorial called for additional studies using "more robust" data sets to confirm and expand on these findings, especially in younger patients,
but agreed that "acute infection, particularly a more severe infection that requires hospitalization, should be considered
a trigger for acute VTE." The study's findings "provide evidence suggesting that blood transfusion and treatment with erythropoiesis-stimulating
agents should now be considered as possible triggers for acute VTE in non-cancer patients," the editorialist added.

VTE prophylaxis

UFH, LMWH similar in cost, efficacy for VTE prophylaxis

Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) have similar costs and effectiveness for venous thromboembolism
(VTE) prophylaxis, but LMWH is associated with fewer complications, a new study found.

In a retrospective cohort study using a national sample of hospitals, researchers compared the risk of VTE, bleeding, heparin-induced
thrombocytopenia (HIT), and death associated with UFH and LMWH. Patients in the study had been discharged between Jan. 1,
2004 and June 30, 2005 from 333 acute care facilities that participated in Premier's Perspective database. All 32,104 patients
had an ICD-9-CM diagnosis code that put them at moderate-to-high risk of VTE (congestive heart failure, stroke, pneumonia,
or urinary tract infection), and received daily prophylactic dosages of either 40 mg LMWH or 10,000–15,000 units of
UFH by hospital day 2. Patients received medication until discharge or until they developed a VTE or a complication related
to heparin. Hospital-acquired VTE was defined as a secondary diagnosis of VTE combined with a diagnostic test for VTE after
hospital day two, followed by treatment for VTE for at least half of remaining hospital days, or until warfarin was started
or a complication occurred (like transfusion). Patients readmitted within 30 days with a primary diagnosis of VTE were also
considered to have hospital-acquired VTE.

Fifty-five percent of patients received LMWH and 45% received UFH. VTE occurred in 163 (0.51%) patients, and complications
that led to stopping therapy were rare (<0.2%). In propensity-adjusted analysis, patients treated with UFH had a non-significant
odds ratio for VTE of 1.04 compared to LMWH. In a grouped treatment model, the odds of VTE with UFH was non-significant at
1.14. Adjusted odds of bleeding with UFH compared to LMWH were 1.64 (95% confidence interval [CI], 0.50-5.33); adjusted odds
of complications that halted prophylaxis were 2.84 (95% CI, 1.43-45.66); and adjusted cost ratio was 0.97 (95% CI, 0.90-1.05).
Hospitals that mostly used UFH had a transfusion rate of 0.60% versus 0.76% at hospitals that mostly used LMWH (P=0.54), indicating that the higher risk of major bleeding associated with UFH was not confounded by local transfusion practices. Results were published online April 2 by the Journal of Hospital Medicine.

Previous randomized controlled trials comparing LMWH and UFH have been small, industry-funded and "used endpoints of uncertain
significance" (like asymptomatic DVT assessed by ultrasound), the authors noted. While the current study found no difference
in effectiveness or cost of the two treatments, LMWH was less likely to be associated with bleeding. "In addition, LMWH is
more convenient since it can be dosed once daily, and for that reason may be more acceptable to patients," the authors wrote.
"For these reasons, LMWH may be the drug of choice for inpatient prophylaxis of general medical patients."

Adverse drug events

Fluoroquinolones associated with retinal detachment

Current users of oral fluoroquinolones were nearly five times more likely to have a retinal detachment than nonusers, although
the absolute risk was small, a study found.

To examine the association between use of oral fluoroquinolones and the risk of developing a retinal detachment, researchers
conducted a nested case-control study of patients in British Columbia, Canada, who had visited an ophthalmologist between
January 2000 and December 2007.

Current users were those with a prescription that overlapped the index date. A recent user was defined as having a prescription
1 to 7 days prior to the index date, and a past user was defined as having a prescription 8 to 365 days before the index date.

As an additional control, researchers also examined the risk of retinal detachment against two drug classes not associated
with retinal detachment: oral β-lactam antibiotics (all oral penicillins and cephalosporins) and short-acting β-agonists.

Among 989,591 patients, 4,384 cases of retinal detachment and 43,840 controls were identified. Current use of fluoroquinolones
was associated with a higher risk of developing a retinal detachment (3.3% of cases vs. 0.6% of controls; adjusted rate ratio
[ARR], 4.50). Neither recent use (0.3% of cases vs. 0.2% of controls; ARR, 0.92) nor past use (6.6% of cases vs. 6.1% of controls;
ARR, 1.03) was associated with a retinal detachment. There was no evidence of an association between retinal detachments and
β-lactam antibiotics (ARR, 0.74) or short-acting β-agonists (ARR, 0.95).

The absolute increase in the risk of a retinal detachment associated with fluoroquinolones was 4 per 10,000 person-years.
The number needed to harm was 2,500 for any use of fluoroquinolones.

The retina is attached to the cortical vitreous by collagen fibers, and fluoroquinolones have been shown to interfere with
collagen synthesis. Just two doses of oral ciprofloxacin can reach antibacterial concentration in the vitreous, the authors
noted. Although the absolute risk is small, fluoroquinolones are a commonly prescribed drug and 40% of people who experience
a detachment could permanently lose at least some visual acuity, they noted.

From the College

Attend a chapter meeting

Clinicians can enhance their clinical skills and knowledge and network with colleagues at local ACP chapter meetings. ACP
members and nonmembers alike can gain insight into recent medical advances, discuss local and national issues affecting internal
medicine, and learn about the benefits of membership. ACP chapter meetings will help clinicians meet not only their needs
as a general internist, subspecialty internist, family practitioner, fellow in subspecialty training, allied health practitioner,
or resident, but also the needs of the patients they serve. More information about upcoming meetings, CME offerings and registration
is available online.

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